P.A.L.S
Pediatric Advanced Life Support
Airway management
Respiratory Anatomy
• Nose and mouth
warms, moisten, filters air
• Pharynx
– Oropharynx
– Nasopharynx
• Epiglottis
• Trachea
2
Anatomical difference between adult and pediatric
• Nose
– Obligatory nasal breathing
– Poor tolerance to obstruction
• Head
– Relatively large
• Tongues
– Large
– Loss of tone with sleep, sedation, CNS
dysfunction
– Frequent cause of upper airway obstruction
Anatomical difference between adult and pediatric
• Epiglottis
– Relatively large size in children
– Omega shaped
– Floppy – not much cartilage
• Larynx
– High position
– Anterior position
• Cricoid cartilage
– less developed and less rigid.
– the narrowest part of airway
• Trachea
– narrower and more flexible
Children are different
Correct (sniffing) position
for maximal airway patency
Airway Positioning
Opening the Mouth
• Crossed-finger technique
• Inspect the mouth
Vomit
Blood
Secretions
Foreign bodies
8
Crossed-finger technique for opening the airway
Finger sweep maneuver
Opening the Airway
• Head Tilt Chin lift maneuver
• Jaw thrust maneuver
• Combined
Remember : C-spine stabilization
Head Tilt Chin lift maneuver
Head-tilt/chin-lift maneuver
Jaw thrust
Neck trauma
Combined
Opening or securing the Airway
• Bag-Mask Ventilation
• Oropharyngeal Airway/Nasopharyngeal
Airway
• LMA
• Combitube
• ETT
Oropharyngeal Airway
Correct Size
Insertion
Oral Airway
Wrong size: Too Long
Oral Airway
Wrong size: Too Short
Oral Airway
Correct size
Nasopharyngeal Airway
• For maintaining airway in “more awake” patients
• Sits in nasopharynx and opens airway
Nasopharyngeal Airway
• Size: Estimate by comparing
to patients little Finger
• Length: Nostril to Tragus
• Insertion :Lubricate
Gently push posterior towards ear
on same side
Nasopharyngeal Airway
Contraindications :
Basilar skull fracture
CSF leak
Coagulopathy
ETT as a Nasal airway
Pediatric Bag-Mask Ventilation
*
Laryngeal Mask Airway(LMA)
•
•
•
•
•
•
•
Advanced airway
Useful alternative for “difficult intubation”
Easy to use
Limited Paediatric use
Not always successful
Sits on larynx
Protects lungs?
When to use LMA
Bag-mask ventilation
is unsuccessful and
endotrecheal
intubation is not
possible
LMA Insertion
LMA Insertion
LMA Insertion
Intubation
• Larynx cephalad and anterior in children
• Practitioner may need to be lower than
patient and look up
Intubation
Age
kg
ETT
Newborn
3 mos
1 yr
2 yrs
3.5
6.0
10
12
3.5
3.5
4.0
4.5
Length (lip)
9
10
11
12
Children > 2 years:
ETT size (uncuffed): Age/4 + 4
ETT size (cuffed):
Age/4 + 3.5
ETT depth (lip):
Age/2 + 12
Laryngoscope Blades
Macintosh
Miller
Airway positioning for children <2yrs
Curved Blade Attaches to Laryngoscope Handle
Keep in left hand
Visualization of Vocal Cords
Anatomy
Vallecula
Tongue
Epiglottis
Vocal
cord
Glottic
opening
Arytenoid
cartilage
Straight Laryngoscope
Better in
younger
children with a
floppy epiglottis
Straight Laryngoscope Blade – used to
pick up the epiglottis
Curved Laryngoscope
Better in
older children
who have a
stiff epiglottis
The tip of the laryngoscope was positioned in the vallecula.